The percent decline in smoking prevalence in adults has slowed to almost zero since 1990, and the gap between low socioeconomic status (SES) and high SES smokers is widening. Underserved smokers are an NCI priority and present a challenge for treatment. They are hard to reach, motivate, treat, and have limited resources and access to this treatment is limited for poor and underinsured smokers. A model managed care demonstration initiative for Medicaid patients (Rite Care) has been implemented in our state. Medicaid patients are seen in 3 large primary care clinics, presenting an opportunity to evaluate the efficacy of TNP treatment for smokers in this population. However, it remains unclear to what degree adjunctive behavioral treatments are needed to increase motivation to quit smoking, use the patch, and quit smoking. Therefore we propose to test, in combination with TNP, the incremental efficacy of a maximal, tailored, and sustained behavioral intervention over a minimal intervention. Interventions will be delivered through primary care medical clinics. The defined population comprises low income, less education smokers who vary in their level of motivation to quit smoking. Patients (n=8760 will be randomly assigned within primary clinics to one of two interventions (a) TNP prescription plus brief physician advice and follow-up (minimal care); and (b) TNP prescription, brief physician advice and follow-up, with the addition of a tailored motivational intervention, a behavioral skills counseling session for smoking cessation, and continued telephone counseling (maximal care). Including multiple providers and contacts, motivational intervention with feedback, behavioral skills training, and follow-up telephone counseling is designed to increase efficacy of treatment when TNP is provided in the maximal treatment condition. These treatment components have been selected to maximize efficacy while maintaining cost efficiency and generalizability. We hypothesize that 6 month 7-day point prevalence quit rates will be 6% and 12% in each of the two treatment groups, respectively. This study is the first to evaluate the efficacy of increasing intensity of behavioral treatment in combination with TNP in a low income Medicaid population in a primary care medical setting. If successful, the results of this study can be readily generalized to similar populations and settings where, increasingly, the burden of smoking-related illnesses is felt most acutely.